By S. Potros. Kean University. 2018.
It is essential that diet therapy continue as the 30% of calories from fat order 100mg kamagra gold mastercard, less than 10% of calories from beneﬁts of diet and drug therapy are additive generic kamagra gold 100 mg visa. A Step II diet contains no more than 30% of calories from fat, less than 7% of calo- DRUG THERAPY OF DYSLIPIDEMIA ries from saturated fat, and less than 200 mg of choles- terol per day. The Step II diet is more stringent and may Dyslipidemic drugs are used to decrease blood lipids, to pre- be used initially in clients with more severe dyslipidemia, vent or delay the development of atherosclerotic plaque, pro- cardiovascular disease, or diabetes mellitus. It can de- mote the regression of existing atherosclerotic plaque, and crease LDL cholesterol levels by 8% to 15%. The drugs act by altering the production, metabo- levels, and they lower HDL cholesterol concentrations. Drug therapy is • Use the Mediterranean diet, which includes moderate recommended when approximately 6 months of dietary and amounts of monounsaturated fats (eg, canola and olive other lifestyle changes fail to decrease dyslipidemia to an ac- oils) and polyunsaturated fats (eg, safﬂower, corn, cot- ceptable level. It is also recommended for clients with signs tonseed, sesame, soybean, sunﬂower oils), to also de- and symptoms of coronary heart disease, a strong family his- crease risks of cardiovascular disease. Categories of drugs are described in this sec- lowering margarines (eg, Benecol and Take Control) tion; individual drugs are listed in Drugs at a Glance: Dys- can help reduce cholesterol levels. This increases blood levels decreasing production of cholesterol, these drugs decrease total of HDL. They reduce LDL cholesterol within 2 weeks and In addition to numerous other beneﬁts, HDL levels are reach maximal effects in approximately 4 to 6 weeks. Studies indicate that these drugs can reduce management includes efforts to achieve desirable body the blood levels of C-reactive protein (CRP) that is associated weight, ingest low amounts of saturated fat and choles- with severe arterial inﬂammation that leads to heart attacks terol, exercise regularly, stop smoking, and reduce al- and strokes. The incidence of coronary artery disease is re- cohol intake, if indicated. The goal is to reduce serum duced by 25% to 60% and the risk of death from any cause triglyceride levels to 200 mg/dL or less. They also reduce the risk of angina • Unless lipid levels are severely elevated, a minimum of pectoris and peripheral arterial disease as well as the need for 6 months of intensive diet therapy and lifestyle modiﬁ- angioplasty and coronary artery grafting to increase or restore cation should be undertaken before drug therapy is con- blood ﬂow to the myocardium. CHAPTER 58 DRUGS FOR DYSLIPIDEMIA 855 Drugs at a Glance: Dyslipidemic Agents Routes and Dosage Ranges Clinical Indications Generic/Trade Name (Type of Dyslipidemia) Adults Children HMG-CoA Reductase Inhibitors (Statins) Atorvastatin (Lipitor) Types IIa and IIb PO 10–80 mg daily in a single dose Fluvastatin (Lescol, Types IIa and IIb PO 40–80 mg daily in 1 or 2 doses Lescol XL) Lovastatin (Mevacor, Types IIa and IIb PO 10–80 mg daily in 1 or 2 doses <10 y: not recommended Altocor) 10–17 y: 10–40 mg daily Pravastatin (Pravachol) Types IIa and IIb PO 40–80 mg once daily Elderly, PO 10 mg once daily Simvastatin (Zocor) Types IV and V (hyper- PO 5–80 mg once daily in the evening triglyceridemia) Elderly, PO 5–20 mg once daily in the evening Fibrates Fenoﬁbrate (Tricor) Types IV, V (hyper- PO 67 mg daily, increased if necessary triglyceridemia) to a maximum dose of 201 mg daily Gemﬁbrozil (Lopid) Types IV, V (hyper- PO 900–1500 mg daily, usually 1200 mg triglyceridemia) in 2 divided doses, 30 min before morning and evening meals Bile Acid Sequestrants Cholestyramine (Questran) Type IIa PO tablets 4 g once or twice daily ini- 240 mg/kg/d in 3 divided doses tially, gradually increased at monthly intervals to 8–16 g daily in 2 divided doses. LDL cholesterol levels de- extensive ﬁrst-past metabolism by the liver, which results in crease within a week of starting these drugs and reach maxi- low levels of drug available for general circulation. When the drugs are stopped, lism occurs in the liver with 80% to 85% of drug metabolites pretreatment LDL cholesterol levels return within a month. These drugs are used mainly to reduce LDL cholesterol Statins are usually well tolerated; the most common further in clients who are already receiving a statin drug. The adverse effects (nausea, constipation, diarrhea, abdominal inhibition of cholesterol synthesis by a statin makes bile cramps or pain, headache, skin rash) are usually mild and acid–binding drugs more effective. More serious reactions include rare occurrences of tion increases HDL cholesterol and can further reduce the hepatotoxicity and myopathy. Bile acid sequestrants (eg, cholestyramine) bind bile These drugs are not absorbed systemically and their main acids in the intestinal lumen. This causes the bile acids to adverse effects are abdominal fullness, flatulence, and be excreted in feces and prevents their being recirculated to constipation. Loss of bile acids stimulates hepatic synthesis of more medications (eg, digoxin, folic acid, glipizide, propranolol, bile acids from cholesterol. As more hepatic cholesterol is tetracyclines, thiazide diuretics, thyroid hormones, fat-soluble 856 SECTION 9 DRUGS AFFECTING THE CARDIOVASCULAR SYSTEM How Can You Avoid This Medication Error? Gribble, a 79-year-old nursing home resident, likes to take all of her medications together. You monitor her pulse and blood pressure before administration and they are within normal cular disease. What, if any, additional precautions should be used when • Identify risk factors: Questran is administered? Other drugs should be taken at least • Obesity 1 hour before or 4 hours after cholestyramine or colestipol. In • Inadequate exercise addition, dosage of the interactive drug may need to be changed • Cigarette smoking when a bile acid sequestrant is added or withdrawn. The • Signs and symptoms depend on the speciﬁc problem: drugs increase the oxidation of fatty acids in liver and muscle • Dyslipidemia is manifested by elevated serum cho- tissue and thereby decrease hepatic production of triglycerides, lesterol (>240 mg/100 mL) or triglycerides (>200 mg/ decrease VLDL cholesterol, and increase HDL cholesterol. These are the most effective drugs for reducing serum triglyc- • Coronary artery atherosclerosis is manifested by eride levels, and their main indication for use is high serum myocardial ischemia (angina pectoris, myocardial in- triglyceride levels (>500 mg/dL). In clients with coro- • Cerebrovascular insufficiency may be manifested nary artery disease, management with gemﬁbrozil is associated by syncope, memory loss, transient ischemic attacks with regression of atherosclerotic lesions on angiography. Impairment of blood ﬂow to the These drugs are well absorbed following oral administra- brain is caused primarily by atherosclerosis in the tion. Metabolism occurs in the liver and excretion is by uri- carotid, vertebral, or cerebral arteries. The main adverse effects are gastrointestinal • Peripheral arterial insufﬁciency is manifested by im- discomfort and diarrhea, which may occur less often with paired blood ﬂow in the legs (weak or absent pulses; fenoﬁbrate than with gemﬁbrozil. The drugs may also in- cool, pale extremities; intermittent claudication; leg pain crease cholesterol concentration in the biliary tract and cause at rest; and development of gangrene, usually in the toes gallstones. For clients receiving warfarin, warfarin dosage because they are most distal to blood supply). This con- should be substantially decreased because ﬁbrates displace dition results from atherosclerosis in the distal abdomi- warfarin from binding sites on serum albumin. It inhibits mobilization of free fatty acids from peripheral tissues, thereby reducing hepatic synthesis of Nursing Diagnoses triglycerides and secretion of VLDL, which leads to decreased • Ineffective Tissue Perfusion: related to interruption of production of LDL cholesterol.
The hypothalamus produces hormones that act on the anterior pituitary or are stored in the posterior pituitary proven kamagra gold 100mg. The anterior pituitary produces hormones that act on various body tissues and stimulate production of other hormones purchase kamagra gold 100 mg otc. A long-acting somatostatin analog, octreotide (Sando- Growth hormone release-inhibiting hormone (so- statin), may be used to treat acromegaly and TSH-secreting matostatin) inhibits release of growth hormone. It is distributed throughout the brain and of thyroid-stimulating hormone (TSH or thyrotropin) in re- spinal cord, where it functions as a neurotransmitter. TRH may be used is also found in the intestines and the pancreas (where it in diagnostic tests of pituitary function and hyperthyroidism. Somatostatin Gonadotropin-releasing hormone (GnRH) causes re- secretion is increased by several neurotransmitters, includ- lease of follicle-stimulating hormone (FSH) and luteinizing ing acetylcholine, dopamine, epinephrine, GABA, and nor- hormone (LH). In addition to inhibiting growth hormone, somatostatin also Prolactin-releasing factor is active during lactation after inhibits other functions, including secretion of corticotropin, childbirth. Hypothalamic somatostatin blocks the action of GHRH Anterior Pituitary Hormones and decreases thyrotropin-releasing hormone (TRH)-induced release of TSH. Growth hormone stimulates secretion of so- The anterior pituitary gland produces seven hormones. Lack of progesterone Corticotropin, also called ACTH, stimulates the adrenal causes slough and discharge of the endometrial lining as cortex to produce corticosteroids. Growth hormone, also called somatotropin, stimulates Prolactin plays a part in milk production by nursing growth of body tissues. It is not usually secreted in nonpregnant women and number, including growth of muscle cells and lengthen- because of the hypothalamic hormone PIF. During late ing of bone, largely by affecting metabolism of carbohydrate, pregnancy and lactation, various stimuli, including suck- protein, fat, and bone tissue. For example, it regulates cell di- ling, inhibit the production of PIF, and thus prolactin is syn- vision and protein synthesis required for normal growth. Deﬁcient growth pigmentation, but its function in humans is not clearly hormone in children produces dwarﬁsm, a condition marked delineated. Deﬁcient hormone in adults (less than expected for age) can Posterior Pituitary Hormones cause increased fat, reduced skeletal and heart muscle mass, re- duced strength, reduced ability to exercise, and worsened cho- The posterior pituitary gland stores and releases two hormones lesterol levels (ie, increased low-density lipoprotein [LDL] that are synthesized by nerve cells in the hypothalamus. When ADH is secreted, Excessive growth hormone in preadolescent children pro- it makes renal tubules more permeable to water. This allows duces gigantism, resulting in heights of 8 or 9 feet if untreated. In the absence of ADH, little water is which distorts facial features and is associated with an in- reabsorbed, and large amounts are lost in the urine. Antidiuretic hormone is secreted when body ﬂuids become Thyrotropin (also called TSH) regulates secretion of thy- concentrated (high amounts of electrolytes in proportion to the roid hormones. Thyrotropin secretion is controlled by a neg- amount of water) and when blood volume is low. FSH, one of the gonadotropins, stimulates functions of sex Oxytocin functions in childbirth and lactation. It is produced by the anterior pituitary gland of both uterine contractions at the end of gestation to induce child- sexes, beginning at puberty. FSH acts on the ovaries in a cycli- birth, and it causes milk to move from breast glands to nipples cal fashion during the reproductive years, stimulating growth so the infant can obtain the milk by suckling. These follicles then produce estrogen, which prepares the endometrium for implantation of a fertil- ized ovum. FSH acts on the testes to stimulate the production THERAPEUTIC LIMITATIONS and growth of sperm (spermatogenesis), but it does not stimu- late secretion of male sex hormones. Drug preparations of FSH There are few therapeutic uses for hypothalamic hormones include urofollitropin (Fertinex), follitropin alfa (Gonal-F), and pituitary hormones. Pituitary hormones late ovarian function in the treatment of infertility. In women, LH is important in the mones (eg, corticosteroids, thyroid hormones, male or female maturation and rupture of the ovarian follicle (ovulation). However, the hormones perform impor- during the last half of the menstrual cycle. When blood pro- tant functions when used in particular circumstances, and gesterone levels rise, a negative feedback effect is exerted on drug formulations of most hormones have been synthesized hypothalamic and anterior pituitary secretion of gonadotropins. Indications for use, Growth hormone is synthesized from bacteria by recom- routes, and dosage ranges are listed in Drugs at a Glance: binant DNA technology. The main clinical use of the drugs is for children whose growth is im- Hypothalamic Hormones paired by a deﬁciency of endogenous hormone. The drugs are ineffective when impaired growth results from other causes or Gonadorelin (Factrel), goserelin (Zoladex), histrelin (Sup- after puberty, when epiphyses of the long bones have closed. After initial stimulation of LH and FSH secretion, (a genetic disorder that occurs in girls). In adults, the drugs chronic administration of therapeutic doses inhibits gona- may be used to treat deficiency states (eg, those caused by dotropin secretion. This action results in decreased produc- disease, surgery, or radiation of the pituitary gland) or the tis- tion of testosterone and estrogen, which is reversible when sue wasting associated with acquired immunodeﬁciency syn- drug administration is stopped. In general, dosage should be individualized according duced to castrate levels. Excessive administration can cause excessive are reduced to postmenopausal levels.
According to to quieten patients generic 100 mg kamagra gold with visa, replacing physical fetters Dr Cotton: with pharmacological ones best 100mg kamagra gold. And despite the best efforts of the advocates of the moral treatment The so called functional psychoses we believe approach, asylums housing the insane often today to be due to a combination of many remained depressing and degrading places until factors, but the most constant one is the intra- well into the twentieth century, as is illustrated cerebral, bio-chemical cellular disturbance arising by the following account of a visit by a newly from circulating toxins originating in chronic appointed psychiatrist in 1953 to the chronic foci of infection, situated anywhere in the body, ward of a mental hospital in Cambridge in the associated probably with secondary disturbance United Kingdom: of the endocrin system. Instead of considering the psychosis as a disease entity, it should be considered as a symptom, and often a terminal I was taken in by someone who had a key to unlock symptom of a long continued masked infection, the the door and lock it behind you. This led into a big Dr Cotton identiﬁed infection of the teeth and bare room, overcrowded with people, with scrubbed tonsils as the most important foci to be consid- ﬂoors, bare wooden tables, benches screwed to the ered, but the stomach and in female patients, the ﬂoor, people milling around in shapeless clothing. At the back of the infected tissue, all infected teeth and tonsils cer- ward were the padded cells, in which would be tainly and for many patients, colectomies. Addi- one or two patients, smeared with faeces, shouting tionally female patients might require enucleation OVERVIEW 237 of the cervix, or in some cases complete removal became popular in the 1930s and 1940s. Such treatment coma, for example, required patients to be given was, according to Dr Cotton, enormously suc- large doses of insulin which, by lowering the cessful with, out of 1400 patients treated, only blood sugar, induced a comatose state from which 42 needing to remain in hospital. According to Sargant and Slater,5 choses was not universally accepted, neither were the striking results said to have been obtained (reproduced with permission of Elsevier Science) by the removal of these infections. To achieve this laudable schizophrenics coming under observation, and it is if somewhat pious aim, Kopeloff and Cheney therefore important not to waste the treatment on planned their study in the form of an experiment. All members of one group received operative treatment for foci Perhaps the most severe of the physical therapies of infection in teeth and tonsils, while members was a lobotomy, where the brain was cut with of the other group received no such treatment and a knife. The operation was pioneered by Egas consequently could be regarded as controls. Evaluation of the effectiveness of entiﬁc limitations it did produce results (sum- the therapy was largely anecdotal, and even marised here in Table 15. That by Karagulla,9 for example, and inconsiderate behaviour, and that the more compared results for six groups of patients. Two immediate translation of thought and feeling into groups, men and women, had been treated at action can show itself in errors of judgement. The the Royal Edinburgh Hospital for Mental and damage, once done, is irreparable. The other four groups had been treated in the years 1940–48, two Both insulin therapy and lobotomies were slowly (men and women) by ECT and two others (men phased out as treatments for the mentally ill, but and women) not using ECT. It requires little another of the physical therapies introduced in imagination to suppose that the historical controls the mid-twentieth century, electric shock (ECT), seen during the period 1900–39 are of little remains in use to this day largely because it has use in evaluating ECT; any difference between been found to be effective in a number of studies the recovery rates for the periods 1900–39 (see next section). This treatment, introduced and 1940–48 in favour of the latter could be by Cerletti and Bini, consists of producing explained by many other factors than treatment convulsions in a patient by means of passing with ECT. The differences between the ECT an electric current through two electrodes placed groups and the concurrent controls are also on the forehead. The idea that such convulsions virtually impossible to assess since the decision might help the mentally ill patient was not new; to use ECT on a patient was a subjective one as long ago as 1798, for example, Weickhardt had by the clinicians involved. There is no way of recommended the giving of camphor to the point knowing whether the treated and untreated groups of producing vertigo and epileptic ﬁts. ECT was (and is) used primarily in the treat- But the evaluation of treatments in medicine ment of patients with severe depression. Early in general and psychiatry in particular was about claims for its effectiveness bordered on the mirac- 6 to be placed on a scientiﬁcally far ﬁrmer footing, ulous. Batt, for example, reported a recovery 7 by the introduction and then the increasing use rate of 87%. Fitzgerald was only slightly less and acceptance of the controlled clinical trial. In nei- ther report however was there any attempt to gather data on recovery rates in concurrent con- PSYCHIATRIC TREATMENTS AND THEIR trols. Despite this, other psychiatrists accepted EVALUATION: THE 1950s ONWARDS the quoted recovery rates as an indication of the effectiveness of ECT. It was Fisher who recognised the need for Some researchers attempted to evaluate ECT by randomisation to treatment groups in medical, comparing their results with those from historical biological and agricultural experiments, and the controls or from concurrent patients who for eventual adoption of the principle into the eval- one reason or another had not been offered the uation of treatments has led to what Sir David treatment of choice (ECT). In such trials patients differences, the use of randomisation represented are assigned to treatment groups according to a great improvement over earlier studies. This was a multicentre trial deciding which treatment a patient would receive. As well The ﬁrst trial with a properly randomised control as demonstrating the effectiveness of ECT in group was that for streptomycin in the treatment the treatment of depression, the MRC trial also of pulmonary tuberculosis, carried out by Brad- showed that a large multicentre trial in psychiatry ford Hill in 1947. In a letter to the British Medical Journal, in the evaluation of psychiatric treatments, par- Sargant12 wrote: ticularly the physical treatments, appears to have been Lewis. An organised experiment would demand much (Sargant W Antidepressant drugs. Reproduced with permission from ing voluntary acceptance by independent hospi- the BMJ Publishing Group) tals and clinics of an agreed procedure for the selection, management, evaluation of mental state, and follow-up investigation of treated, as well as At the end of the 1940s and the beginning of of control cases. The discovery of these drugs was not based on a physical therapies, such as insulin coma and scientiﬁc knowledge of brain chemicals, rather psychosurgery remained in use, with advocates their discovery was for the most part serendip- of these treatments retaining their enthusiasm, ity, resulting from acute observations made by apparently untroubled by the usual requirements clinicians such as Henri Laborit (the effects of rational scientiﬁc scepticism. Demands that of the antihistamine promethazine, from which clinical trial methodology be adopted to evaluate developed chlorpromazine), and John Cade who treatments whose effectiveness most psychiatrists ﬁrst described the value of lithium in manic already took for granted, fell largely on deaf ears. The tricyclic antidepressants 1950s Miller and his colleagues randomly allo- and the Selective Serotonin Reuptake Inhibitors cated ten schizophrenic patients to each of (SSRIs), which had fewer side effects in treating three alternative treatments, ECT, Pentothal and depression, were also discovered in the 1950s. Pentothal plus non-convulsive stimulation, and Finally, almost by accident, Leo Sternback in assessed them before treatment began, after the 1957 identiﬁed the benzodiazepines for treating cessation of treatment, and then again two weeks mild anxiety. Drug treatment of satisfy regulatory authorities (prior to 1960 only schizophrenia, depression and anxiety disorders the USA had such a body overseeing the intro- have, in randomised clinical trials, been found duction of new drugs into general use, but to be effective and have done much to alleviate the thalidomide tragedy changed the situation the misery of these conditions.
Whatever reasons drove them to become invalids in the ﬁrst place are best left alone discount 100 mg kamagra gold overnight delivery. On all my subsequent house calls discount 100mg kamagra gold fast delivery, I just sat and listened to Miss Cootsie tell me about everybody who had passed on the street below. In addition, she described in great detail her constant and continuing problems with her irregu- lar bowel habits. Te heights of success with Irene Johnson were balanced by the low of the clinical defeat with Miss Cootsie. He had me tell him the story over and over in the lounge, as he doubled over with laughter. Doherty said, You know, medicine is very diﬀerent now from when I came along. Te small, completely segregated hospital was located at the edge of town in an old house that had been converted into a ﬁfteen-bed hospital. Six of the beds were lo- cated upstairs at the rear of the house in what had previously served as a sleeping porch. Doherty went on to tell me that the patient (I will call him Vance Vanders) had been ill for many weeks and had lost a large amount of weight, estimated to be ﬁfty or more pounds. Te clinical suspicions in those days for anyone with a wasting disease were either tuberculosis or widespread cancer. Re- peated tests and chest x-rays for both these diseases were nega- tive, as was the physical examination. Despite a nasogastric feeding tube, Vance Vanders continued on a downhill course, refusing to eat and vomiting whatever was put down the tube. He said repeat- edly he was going to die, and he soon reached a stage of near stupor. Drifting in and out of consciousness, he was barely strong enough 27 28 Symptoms of Unknown Origin to talk. Only then did his wife, who had stayed by his bedside, ask to talk to Dr. Doherty: About four months before Vanders was admitted to the hospital, he had a run-in with the local witch doctor or priest, as he was called. It was well known that many blacks of the area practiced voodoo and that there were several priests in the region. Te wife had not been able to uncover why he called Vanders, only that an argument oc- curred. Te priest told Vanders that he had voodooed him and that Vanders would die in the very near future, that there was no way out, and that even the medical doctors could not save him. Several weeks later, he was admitted to the small hospital in a moribund state. Neither the wife nor Vanders had come forward to tell the story because the voodoo priest had told them he would voodoo all their children and as many other people as it took to keep them silent. Knowing that Vanders was very near death, he spent a lot of time that night thinking about what approach he should take. Whatever he did, he knew it had to be done right away or Vanders would cer- tainly die. Tey were trembling and frightened to be associated with this doomed man. Doherty announced in his most authoritative voice that he now knew exactly what was wrong with Vanders. He told them of a harrowing encounter at midnight the night before in the local cem- etery, where he had lured the voodoo priest on some false pretense. Doherty said he told the priest that he had uncovered his secret voodoo and found out precisely how he had voodooed Vanders. Doherty said he choked the priest against a tree nearly to death until the priest described exactly what he had done to Vanders. Doherty told Vanders and the small crowd of kin who had gathered around the bed. All but one of them died, leaving one large one which is eating up all your food and the lining of your body. I will now get that lizard out of your system and cure you of this horrible curse. She had, by prearrange- ment, ﬁlled a large syringe with apomorphine (a powerful inject- able emetic). Doherty pointed the syringe to the ceiling and inspected it most carefully for several moments. He squirted the smallest amount of clear liquid into the air and lunged toward Vanders. Te patient by now had gathered enough strength to be sitting up wide-eyed in the bed. He pressed himself against the headboard, trying to escape the injection. With that he wheeled about, said nothing, and dramatically left the ward. In a few minutes, the nurse reported that Vanders was begin- ning to vomit. Doherty arrived at the bedside, Vanders 30 Symptoms of Unknown Origin was retching, one wave of spasms after another.
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